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PubMed2004

Measurement and treatment of elevated blood pressure in the pediatric patient with chronic kidney disease.

Hypertension, as in adults, is a frequent complication found in children with chronic kidney disease (CKD). Indeed, hypertension has now become one of the most prevalent chronic diseases of childhood. The most recent data available (2003) indicate that at least 38% of children with CKD in the United States are receiving antihypertensive therapy. Only recently has it been shown in children that hypertension, traditionally considered a marker for disease severity in children, is additionally a significant and independent risk factor for accelerated deterioration of kidney function and progression of CKD and a significant risk factor for cardiovascular disease. The following review outlines the differences and similarities of childhood versus adult hypertension with respect to measurement, diagnosis, treatment, and consequence in CKD. The definition of hypertension changes continually as a child grows with or without CKD. Despite numerous guidelines, the diagnosis of childhood hypertension continues to be based on epidemiologic data rather than evidence. For children, the current definition includes 2 categories: high normal, which is blood pressure (BP) between the 90th and 95th percentile, and hypertensive, which is BP above the 95th percentile. The evaluation of all hypertensive children should include a complete assessment of end-organ damage, including eyes, cardiovascular system (including blood vessels), kidneys, and nervous system. For children with CKD and end-stage renal disease (ESRD), a high percentage have left ventricular hypertrophy (LVH). The finding of end-organ damage or comorbidity (CKD, diabetes) in any child is an absolute indication for immediate pharmacologic therapy, whereas the presence of hypertension above the 95th percentile in children without CKD warrants initial intervention such as life style modification. The guidelines for measurement of BP in children with CKD are similar to those in children without CKD and include casual BP measurement, self-measured BP, and ambulatory BP monitoring. The recommendation for BP measurement in children is, when permitted, by auscultative method with a well-calibrated mercury manometer. Most casual BP measurements are performed with an automated oscillometric device whose validation has not been confirmed in children with CKD. The ambulatory BP monitor (ABPM) has 2 advantages: it significantly correlates with the presence of end-organ damage, and it identifies abnormal BP patterns that are frequently present in CKD patients, such as hypertension during the sleep period. An abnormal ABPM pattern can also be predictive of the development of end-organ damage. Treatment of hypertension in children, with and without CKD, is based on 3 factors: degree of BP elevation, the presence of cardiovascular risk factors, and the presence of end-organ damage. Additionally, the initial antihypertensive agent may be selected on available and age-appropriate formulations (eg, suspension and dosage selection). A physician treating a hypertensive child with CKD faces multiple challenges. They include selecting the convenience of available automated devices and the ABPM versus traditional auscultatory techniques upon which all normative standards have been based. Current research initiatives propose to develop pharmacokinetic and pharmacodynamics properties of antihypertensive medications and to study the effect of early intervention on end-organ damage.

Blood Pressure↗
PubMed2005

General medical care among patients with chronic kidney disease: opportunities for improving outcomes.

Suboptimal health care during advancing chronic kidney disease (CKD) may result in greater morbidity and cost once dialysis is started and may preclude future transplantation. Medicare data were examined for the prevalence of selected general health, diabetes, and CKD interventions in a national cohort of patients in the 2 yr before dialysis initiation and compared with a contemporaneous non-CKD cohort. A total of 24,778 individuals who were aged > or =67 yr composed the CKD cohort, and 1,046,136 individuals who were aged > or =67 yr did not have CKD. Among patients with diabetes and CKD, fewer than two thirds had claims for eye examinations, 75% for HbA(1C) testing, and 68% for lipid testing, with similar proportions in the non-CKD cohort. Among those without diabetes, 47 and 54% of the CKD and non-CKD cohorts, respectively, had claims for lipid testing. Fewer than 50 and 15% had claims for influenza and pneumococcal vaccination, respectively, with slightly lower proportions among patients with CKD. Claims for cancer tests were found for 14 to 41% and 29 to 52% of individuals with and without CKD, respectively, depending on the type of cancer. A greater proportion of patients with diabetes tended to have claims for tests in both cohorts. In the CKD cohort, claims for anemia testing and parathyroid hormone levels were available in fewer than 50 and 15%, respectively, and claims for permanent vascular access were found for only 30% of hemodialysis patients. This study provides further evidence that patients with CKD may not be receiving general health and CKD care according to current recommendations.

Aged↗
PubMed2004

Structure and content of chronic kidney disease information on the World Wide Web: barriers to public understanding of a pandemic.

Chronic kidney disease (CKD) is a pandemic and the need to inform those at risk has never been more important. The World Wide Web (WWW) is no w considered a key source of health information, but the quality and utility of this information has been challenged. In this article, we assess structural, content, and linguistic barriers to accessed CKD information and discuss the implications of limited Internet access to communicating health. Technical (number of hyperlinks), content (number of six core CKD and risk factor information domains included), and linguistic (readability and variation in readability) barriers were assessed for websites offered by 12 kidney disease associations. The Flesch Reading Ease Index method was used to estimate readability scores, and variation in the readability of information was assessed. Eleven websites met inclusion criteria. Six of 11 websites provided information in all 6 domains of CKD information. A mean of 4 hyperlinks (range 3-5) was clicked before CKD information was available and a mean of 6 hyperlinks (range 4-12) was clicked to access all available CKD information. Mean readability scores for all six domains of CKD information exceeded national average literacy skills and far exceeded the 5th grade level readability desired for informing vulnerable populations. Information about CKD and diabetes consistently had higher readability scores. The WWW currently has little utility for informing populations at greatest risk for CKD. Barriers to accessing CKD information on the WWW are socioeconomic, technical, and linguistic. Having lower socioeconomic status, less access to computers and the WWW, multiple website hyperlinks, incomplete information, difficult readability, and significant variation in readability of CKD information on the WWW are social, structural, and content barriers to communicating CKD information. This may contribute to the growing epidemics of diminished public understanding about CKD, and disparities in CKD health status experienced by racial/ethnic minority populations globally.

Computer Literacy↗
PubMed2026

Precision Diagnosis in APOL1 Kidney Disease With the p.N264K M1 Protective Variant.

IMPORTANCE: The APOL1 M1 (p.N264K) variant protects against G2-associated APOL1 focal segmental glomerulosclerosis (FSGS) and chronic kidney disease (CKD). However, the utility of knowing an individual's M1 status in guiding kidney disease diagnosis and other clinical scenarios remains underexplored. OBJECTIVE: To test 2 hypotheses: (1) in patients with APOL1 high-risk (HR) genotype kidney disease with at least 1 G2 allele, M1 can distinguish APOL1 CKD from non-APOL1 CKD; (2) in people with APOL1 low-risk (LR) genotypes, M1 is independently associated with protection against FSGS and CKD. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case-control study using data from 2 tertiary care hospitals (Columbia University Irving Medical Center and Mass General Brigham Biobank) and population-based data (the UK Biobank [UKB], Electronic Medical Records and Genomics [eMERGE-III], and All of Us [AoU]). Participants were individuals with a diagnosis of FSGS or steroid-resistant nephrotic syndrome (SRNS), individuals with CKD, and controls. EXPOSURES: Exposures included the M1 variant (p.N264K) obtained from exome or genome sequencing data, sex, and genetic ancestry. MAIN OUTCOME AND MEASURE: The main outcome was the presence or absence of kidney disease, defined as FSGS or non-FSGS CKD, compared with non-kidney disease controls. Association between the M1 variant and disease status was assessed using odds ratios (ORs). RESULTS: A total of 107 696 individuals (54 994 [51.1%] female; 8779 [8.2%] with African ancestry, 78 475 [72.9%] with European ancestry, and 16 129 [15.0%] with multiethnic ancestry), including 3460 with FSGS or SRNS, 24 382 with non-FSGS CKD kidney disease, and 79 854 controls were enrolled in the discovery cohort. In the APOL1-HR group (1413 participants), M1 was significantly inversely associated with FSGS or SRNS cases compared with controls without kidney disease (OR, 0.20; 95% CI, 0.04-0.63; P = 3.69 × 10-3). Among individuals with CKD with APOL1-HR genotypes, M1 was 4 times more frequent in those whose CKD was not due to FSGS or SRNS. Importantly, electronic health record and biopsy review identified an alternative, non-APOL1 cause for CKD in nearly all APOL1-HR-M1 cases. There was no association between individuals with APOL1-LR genotypes with M1 and protection against CKD or FSGS. CONCLUSIONS AND RELEVANCE: In this case-control study of 107 696 individuals, presence of an APOL1-HR genotype M1 was significantly associated with protection against kidney disease, suggesting that it may have a role as a genetic modifier. Patients with CKD with an APOL1-HR genotype and M1 should be evaluated for an alternative and potentially treatable cause of their CKD.

Humans↗
PubMed2006

Prevalence and severity of anaemia in patients with type 2 diabetic nephropathy and different degrees of chronic renal insufficiency.

BACKGROUND/AIM: Type 2 diabetes mellitus is the single most common cause of chronic kidney disease (CKD); however its real impact on renal anaemia has not been established. The aim of this study was to evaluate whether onset, severity, and prevalence of anaemia during the course of CKD is different between type 2 diabetic and non-diabetic patients. METHODS: We enrolled 281 patients with: (1) type 2 diabetes and no CKD (n = 75); (2) type 2 diabetes plus CKD (n = 106), and (3) CKD without type 2 diabetes (n = 100). According to K/DOQI guidelines, the patients with renal insufficiency (i.e., those with a glomerular filtration rate <60 ml/min) were subgrouped into three tertiles of CKD: (1) stage 3 (creatinine clearance 60-30 ml/min); (2) stage 4 (creatinine clearance 29-15 ml/min), and (3) stage 5 (creatinine clearance <15 ml/min). RESULTS: Anaemia was observed in 16% of the diabetic patients without CKD; it was more frequent in the diabetic patients with CKD than in the non-diabetic patients with CKD (61.7 vs. 52%, p < 0.05). The comparison among the tertiles showed that the prevalence of anaemia was significantly higher only in diabetic CKD patients of stages 4 and 5. The prevalence was higher in females independently of type 2 diabetes mellitus. In diabetics with a normal renal function, the haemoglobin levels were higher than in diabetics and non-diabetics with CKD, but the diabetics showed lower levels of haemoglobin than non-diabetics at stage 3 and stage 4 of CKD. CONCLUSIONS: Diabetic patients with CKD of stages 4 and 5 have a higher prevalence of anaemia than non-diabetic patients with comparable glomerular filtration rate. A higher awareness of this risk will allow earlier diagnosis and treatment.

Aged↗
PubMed2005

Effect of pravastatin in people with diabetes and chronic kidney disease.

Although diabetes is a major cause of chronic kidney disease (CKD), limited data describe the cardiovascular benefit of hydroxymethyl glutaryl CoA reductase inhibitors (statins) in people with both of these conditions. This study sought to determine whether pravastatin reduced the incidence of first or recurrent cardiovascular events in people with non-dialysis-dependent CKD and concomitant diabetes, using data from three randomized trials of pravastatin 40 mg daily versus placebo. CKD was defined by estimated GFR <60 or 60 to 89.9 ml/min per 1.73 m2 with proteinuria. Of 19,737 patients, 4099 (20.8%) had CKD but not diabetes at baseline, 873 (4.4%) had diabetes but not CKD, and 571 (2.9%) had both conditions. The primary composite outcome was time to myocardial infarction, coronary death, or percutaneous/surgical coronary revascularization. Median follow-up was 64 mo. After adjustment for trial and random treatment assignment, the incidence of the primary outcome was lowest in individuals with neither CKD nor diabetes (15.2%), intermediate in individuals with only CKD (18.6%) or only diabetes (21.3%), and highest in individuals with both characteristics (27.0%). Pravastatin reduced the relative likelihood of the primary outcome to a similar extent in subgroups defined by the presence or absence of CKD and diabetes. For example, pravastatin was associated with a significant reduction in the relative risk of the primary outcome by 25% in patients with CKD and concomitant diabetes and by 24% in individuals with neither characteristic. However, the absolute reduction in the risk of the primary outcome as a result of pravastatin use was highest in patients with both CKD and diabetes (6.4%) and lowest in individuals with neither characteristic (3.5%). In conclusion, stage 2 or early stage 3 CKD and diabetes both are associated with higher cardiovascular risk, and pravastatin reduces cardiovascular event rates in people with neither, one, or both characteristics. Given the high absolute benefit of pravastatin in patient with diabetes and stage 2 or early stage 3 CKD, this population in particular should be targeted for widespread use of statins. Additional studies are needed to determine whether these benefits apply to patients with more severe CKD, and recruitment to such studies should be given high priority.

Adult↗
PubMed2005

[The application of glomerular filtration rate estimation equations in different stages of chronic kidney disease].

OBJECTIVE: To understand the applicability of MDRD equation in Chinese patients with chronic kidney disease (CKD). Glomerular filtration rate (GFR) estimated with MDRD equation, abbreviated MDRD equation and Cockcroft-Gault equation was compared with (99m)Tc-DTPA plasma clearance by dual plasma sampling method in different stages of CKD. METHODS: CKD were diagnosed according to K/DOQI guideline.298 patients with CKD were selected. Patients'sex, age, height and body weight were recorded and plasma creatinine, urea nitrogen and albumin were measured in a single clinical laboratory. (99m)Tc-DTPA plasma clearance was calculated and standardized by body surface area (sGFR). GFRs estimated with MDRD equation 7, abbreviated MDRD equation and Cockcroft-Gault equation (7GFR, aGFR and cGFR) were compared with sGFR in different stages of CKD. RESULTS: There were 165 male and 133 female in the selected 298 patients with CKD;the average age was (52.5 +/- 15.5) years. There was significant difference between the GFRs of the 3 equations with sGFR in different stages of CKD (P < 0.001). 7GFR, aGFR and cGFR were significantly higher than sGFR in CKD stages 5-4; the lower the sGFR, the more the differences. 7GFR, aGFR and cGFR were significantly lower than sGFR in CKD stage 2-1; the higher the sGFR, the more the differences. CONCLUSION: Our results showed that in Chinese population with CKD, MDRD equation 7, abbreviated MDRD equation and Cockcroft-Gault equation overestimate actual GFR in CKD stages 4-5 and underestimate GFR in CKD stages 1-2. These results indicate that MDRD equation and its modifications for estimation of GFR should be amended when applying to Chinese patients with CKD in clinical practice.

Adult↗
PubMed2005

Self-assessed sleep quality in chronic kidney disease.

BACKGROUND: Although sleep complaints are commonly reported in persons with end stage renal disease (ESRD), little is known about the prevalence of sleep complaints in chronic kidney disease (CKD), and the relation of sleep quality to the severity of kidney disease. METHODS: We administered the Kidney Disease Quality of Life (KDQOL) sleep scale to 156 subjects, 78 with ESRD and 78 with CKD. Glomerular filtration rate (GFR) was estimated using the six variable Modification of Diet in Renal Disease (MDRD) equation and used to stratify subjects with CKD as mild-moderate (GFR >25 ml/min/1.73 m(2)) and advanced (GFR <25 ml/min/1.73 m(2)). We used multivariable linear regression to determine independent predictors of KDQOL sleep scale scores. Higher scores indicate higher self-reported quality of sleep. RESULTS: Median scores on the KDQOL sleep scale were 59 (interquartile range 40-80) in subjects with ESRD and 69 (interquartile range 53-80) in subjects with CKD (P=0.04). Thirty-four percent of subjects with ESRD, 27% of subjects with advanced CKD, and 14% of subjects with mild to moderate CKD had sleep maintenance disturbances (P=0.05). Thirteen percent of subjects with ESRD, 11% of subjects with advanced CKD, and no subjects with mild-moderate CKD had complaints of daytime somnolence (P=0.03). There was no significant difference in the prevalence of sleep adequacy complaints in persons with ESRD versus CKD. In multivariable analyses, only age and ESRD status (vs. CKD) were significant predictors of lower KDQOL sleep scores. Among subjects with CKD, there was a significant direct association between estimated GFR and scores on the KDQOL sleep scale in non-African American subjects (P=0.01). CONCLUSIONS: Sleep complaints are common in persons with CKD and ESRD and may be associated with the severity of kidney disease.

Aged↗